2. Introduction
•In 1923, Dr. James Sidbury, administered blood through the umbilical
vein to treat HON
•First ET (aka exsanguination, venesection or substitution
transfusion) was reported by Dr.A.P Hart in 1925
3. Definition
•Repetitive withdrawal of small amounts of blood and
replacement with donor blood, until a large portion of
the original volume has been replaced
•Blood volume in neonates: 75 to 105 ml/kg
• Withdrawing a baby’s blood which has high bilirubin
content and replacing it with fresh blood through
umbilical vein.
4. Indications of ExchangeTransfusion
• When phototherapy fails to prevent rise in bilirubin level
• Hemolytic disease of newborn (HON)
• (ABO Incompatibility,Rh Incompatibility)
• Under conditions when
• Cord Hb 10% or less.
• Cord bilirubin 5mg/dl or more.
• Severe sepsis
• Severe anemia causing cardiac failure
• Poisoning
Healthybaby Babywith severeJaundice
5. • Non obstructive jaundice with serum bilirubin level of 20mg/dl or
more in full term and 15mg/dl in preterm infants,
e.g. Rh or ABO incompatibility.
• Kernicterus irrespective of serum bilirubin level.
• Rise of serum bilirubin of more than 1mg/dl/hr
• Maternal antibody titer of 1:64 or more, positive direct
Coomb’s test and previous history of severely affected baby
6. Things to do before exchange
•Admit baby to NICU
•Immediately start phototherapy
•Send blood to assess the total bilirubin and blood grouping
•Stop feed and start IV fluid to hydrate the baby.
•Put in NG tube on drainage.
•Explain treatment and obtain written consent from the parents
7. Equipment required
1. Radiant warmer
2. Respiratory support : Ventilators, ET tube, AMBU bag etc.
3. Suction equipment
4. Multi-Channel Monitor: Heart rate, RR and Sp02
5. Umbilical catheterization set
6. NG tube and umbilical catheter
7. Disposable syringes: 20cc, 1Occ, Sec, 2cc
8. Three way stopcock connector x2 nos
9. Sterile gloves
10. IN tubings
11.Waste recipticle
10. OVERVIEW
The umbilical vein offers a technically easy, relatively
safe and pain free portal for intravascular catheter
access in the newborn.
An umbilical vein catheter (UVC) provides a good
alternative to a peripheral venous catheter that reduces
the need for multiple procedures to maintain venous
access while not being associated with greater risks of
infection.
When the catheter tip is in a good position a UVC can be
left in place for at least 14 days without increased risk of
complications
11. Indications
1. Venous access from early after birth in all very preterm
babies and any other baby requiring respiratory support.
2. For urgent vascular access in resuscitation for
administration of adrenaline or volume expansion.
3. Infusion of hypertonic solutions for example in resistant
hypoglycaemia requiring more than 10% dextrose or
TPN.
4. Exchange transfusion.
12. Preparation
1. Perform calculation and/or measurement to estimate insertion
distance. An approximation of the insertion distance in cms can be
derived from the formula:3 (1.5 x birth weight in kg) + 5.5 .
2. Select size 3.5FG double or single lumen UVC Use 5FG single
lumen for exchange transfusion.
3. Prime the umbilical catheter with 3-way tap attached using
heparinised saline (50 units per 5ml) and leave syringe attached.
Prime both lumens where appropriate.
4. Sterilise the cord and area around the cord with aqueous
chlorhexidine. Do not allow topical antiseptic to pool under the
infant, allow to dry for 3 minutes, then drape the area around the
cord as shown.
5. Remove first set of gloves.
13. Procedure
1. Place sterile cord tie around the base of the cord and tie in a loop
with moderate tension (this is to stop back bleeding).
2. Use the scalpel to cut the cord between the cord clamp and the skin
at the base of the umbilicus. Cut away from you and close to the
clamp. Do not cut flush with the skin as this will limit any further
attempts.
3. Identify the vessels and probe the vein
Examine the cut end of the cord and identify the two arteries (small,
thicker walled and constricted) and the single vein (more gaping and
thin walled).
4. Grasp the edge of the cord with the suture forceps and use the
lacrimal probe or the fine toothed forceps to tease open the vein. It
will usually open up easily.
14.
15. Procedure
Introduce and advance catheter
5. Ease the catheter into the open vein and advance slowly to the
estimated insertion distance. It will usually need only slight
pressure to advance
6. Withdraw on the syringe to test whether you can get free flowing
withdrawal of blood. If you can’t withdraw blood, it usually means
the catheter tip is in the hepatic or portal veins, so withdraw the
catheter slowly until you get free flow of blood.
16.
17. Procedure
Secure the catheter
7. Anchor catheter to base of the cord with a 3/0 silk suture.
8. Secure with tapes as shown
9. Connect catheter to infusion at 1ml/hr to keep catheter open until tip
position confirmed with x-ray.
10. The ideal catheter tip position is at the junction of the ductus
venosus and the inferior vena cava. On x-ray this has the
appearance shown, with the UVC going straight up with the tip at the
level of the diaphragm
18.
19. Complications
1. Catheter Malposition and Extravasation
2. Cardiac Tamponade from extravasation into the pericardium
3. Extravasation in the Liver with Ascites
4. Sepsis
5. Thrombosis
24. Volume of blood for double volume ET
• Volume of blood = Weight (Kg) x 2 x 80ml
• Add additional 20 to 30ml for dead space in tubing
• 20 – 30 ml of blood is withdrawn and 10 – 20 ml are replaced
each time
27. Responsibilities
• A temperature controlled device must be used for warm ng blood
before and during the transfusion
• Record time, vital signs, amount of blood out and in after each cycle
• The blood should be mixed after every exchange to prevent settling
of RBCs. (Procedure takes at least 1 hour)
• Continue phototherapy after ET
• Antibiotic prophylaxis may be considered
